Medicare and Medicaid

Sherrie Bennett

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You may be eligible for these government health care insurance programs:

Medicare

The federal Medicare program is a health insurance program for the elderly and disabled. Medicare is administered by the Centers for Medicare and Medicaid Services ("CMS").

Medicare provides benefits for:

• Those who have reached age 65 and are entitled to receive Social Security or Railroad Retirement benefits
• Disabled individuals of any age who have received Social Security or Railroad disability benefits for at least two years

• Persons eligible for Social Security benefits who have end-stage renal disease and require kidney dialysis treatment
• Persons over age 65 who are not eligible for either Social Security or Railroad Retirement benefits who purchase monthly Medicare coverage

Medicare Reimbursement Programs

Medicare reimburses qualifying health care providers for specific medical services under two separate programs:

Medicare Part A Hospital Insurance Program

This program provides beneficiaries with coverage for mostly hospital-related claims, including:

• Inpatient hospital care
• Limited post-hospital skilled nursing facility
• Home health care
• Hospice care

Medicare Part B Supplementary Medical Insurance Program

This program focuses on medical costs other than hospitalization, such as:

• Physician and surgical services
• Diagnostic tests
• Home health care
• Physical, speech and occupational therapy
• Medical supplies
• Durable medical equipment
• Ambulance services
• Some preventive care services

Enrollment in Part B coverage is optional.

Each program requires different deductible and co-payment amounts.

Medicare Exclusions

Medicare coverage doesn't include:

• Custodial nursing home care
• Most outpatient prescription drugs
• Routine physical examinations
• Routine eye examinations and eyeglasses
• Hearing examinations and hearing aids
• Routine dental services
• Routine foot care and orthopedic shoes
• Most immunizations
• Personal convenience items
• Cosmetic surgery

MedicarePlus Choice Program

Any individual who is entitled to Medicare benefits under Part A and enrolled under Part B, may now choose from several types of health insurance plans under the MedicarePlus Choice program, including:

• Coordinated Care Plans such as health maintenance organizations ("HMOs"), preferred provider organizations ("PPOs"), and provider-sponsored organizations ("PSOs")
• Private Fee-for-Service Plans
• Medical Savings Accounts ("MSAs")

Medigap Plans

Medicare supplemental insurance ("Medigap") plans provide coverage for:

• Medicare deductible and co-payment amounts
• Some health services not covered by Medicare

The federal Qualified Medicare Beneficiary program ("QMB") and the Selected Low-Income Medicare Beneficiaries program ("SLMB") may provide payment for Medicare deductibles and co-payments to qualified individuals.

Medicaid

Medicaid is a jointly-financed federal-state health care program that provides medical assistance to:

• Low-income elderly
• The blind or disabled
• Families with dependent children

Medicaid is the primary public financing program for long-term nursing home and home care services.

Eligibility requirements vary greatly from state to state.

All states, however, must provide Medicaid coverage to the categorically eligible. Categorical eligibility is related to economic need and income.

States may also provide Medicaid coverage to the medically needy, frequently persons in need of expensive nursing home or hospital care.

Generally, Medicaid pays for:

• Inpatient and outpatient hospital services
• Prescription drugs
• Physician services
• Laboratory and X-ray services
• Custodial nursing home care

Benefits vary from state to state, and may also cover:

• Dental care
• Medical equipment
• Foot care
• Optometry services
• Clinic services
• Rehabilitative services
• Transportation to obtain medical care

The Civilian Health and Medical Program of the Uniformed Services ("CHAMPUS") is a federal health benefit program for eligible retired armed forces personnel and family members. The CHAMPUS program is supervised by the National Tri-Care Support Office, which provides a handbook describing program rules and benefits.

Sherrie Bennett is the former director and staff attorney at the University of Washington Student Legal Services in Seattle.

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